Ep. 211: Food Allergy Treatments and What You Need to Know

https://podcasts.apple.com/us/podcast/faacts-roundtable/id1507431265To help you make the best decisions about food allergy treatment choices, we’re exploring current options with board-certified allergist, Dr. Brian Vickery. We’ll discuss what questions to ask your doctor and family when determining the proper treatment for loved ones, including time and financial commitments.

Resources to keep you in the know:

• Navigating Treatment Choices - FAACT
• FAACT's Navigating the Food Allergy Treatment Decision Process

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Sponsored by: Genetech

Thanks for listening! FAACT invites you to discover more exciting food allergy resources at FoodAllergyAwareness.org!

Transcript

[00:09] Caroline: Welcome to FAACT's Roundtable, a podcast dedicated to navigating life with food allergies across the lifespan. Presented in a welcoming format with interviews and open discussions, each episode will explore a specific topic, leaving you with the facts to know or use. Information presented via this podcast is educational and not intended to provide individual medical advice. Please consult with your personal, board-certified allergist or healthcare providers for advice specific to your situation. Hi everyone, I'm Caroline Moassessi and I am your host for the FAACT Roundtable podcast. I am a food allergy parenthood advocate and the founder of the GratefulFoodie blog and I am FAACT's Vice President of Community Relations. Before we start today's podcast, we would like to take a moment to thank Genentech for being a kind sponsor of FAACT's Roundtable podcast. Also, please note that today's guest was not paid by or sponsored by Genentech to participate in this specific podcast. More and more food allergy treatments are becoming available as time progresses. To help you make the best decisions possible, we're exploring current food allergy treatment options with board certified allergist, Doctor Brian Vickery. We'll discuss what questions to ask when determining the proper treatment for you and your family, including time and financial commitments. Welcome back Doctor Vickery to FAACT's Roundtable podcast. We always appreciate your down to earth and easy to understand style, especially about today's conversation, which is going to be just incredible listeners. You're going to be so happy.

[01:59] Dr. Brian Vickery: Well, thanks, Caroline. I appreciate the invitation to come back. Always enjoy the conversations with you.

[02:04] Caroline: Well, we always walk away with new information, and I think for you in particular, we walk away with learning a new way to look at things. So I'm very excited about today's conversation. But before we actually get started, if we can help our new listeners get to know you better, so can you share your background and then why you became so passionate about food allergy?

[02:25] Dr. Brian Vickery: Yeah. So my name's Brian Vickery. I am the chief of allergy immunology at Emory University and Children's Healthcare of Atlanta. Here in Atlanta, which is my hometown. I'm happy to be here. I've been here about six years. Before that, I was in North Carolina, and I've had about 15 year history at this point of working in the food allergy space, in clinical care and also in research. And most of my research has been focused on the development of new treatments for food allergy. So when I got into the field all those years ago, which doesn't feel like that long ago, but it's been a minute now. We really had nothing to offer patients and families from a treatment perspective. It was really, be careful. Avoid this food, here's your rescue medications, your auto injector. If an accident happens, use these medications and then come back and see us next year. That was really almost the entirety of the standard of care, which felt to me really inadequate. And so my motivation from the beginning and still was to do things that would improve outcomes for patients. And at the time, I sort of made the calculation that, well, if we don't have treatments for patients, then one of the best ways I can think of to try to improve outcomes for patients is to develop new treatments that might improve upon that standard of care. And so a lot of my work has been focused in clinical trials that, you know, the outcomes of which would be to develop new treatments. It's been interesting, and this is what we're going to talk about today. We've now succeeded at doing that a few times, and yet I'm still concerned about making sure that we're actually improving outcomes, because I've come to understand that simply just doing clinical trials and getting treatments approved I don't think will by itself lead to better outcomes. So I'm increasingly worried about that. Could talk more about that in the future. I don't think it's quite as simple as just do the trials, new medicine, okay, now everybody's better. There's a lot more work that needs to be done.

[04:32] Caroline: Well, adapting something, learning about it, making decisions, there's a lot to go on there and you're the perfect person.

[04:40] Dr. Brian Vickery: Well, I'll try.

[04:41] Caroline: So let's examine what food allergy treatments are currently available in the US today. Can you explain which treatments are actually readily accessible, like right now? And then, listeners, in a few minutes, we'll explore how you can determine which treatments might suit your family, lifestyle and budgets because you just like Doctor Victery was saying, you can do these trials and have this information, but now you have to figure out how to bring it to life and if it's appropriate for you.

[05:09] Dr. Brian Vickery: Yeah. So when I think about kind of what is available to patients, I mean, increasingly when I see patients in my own clinic, you know, this is a common thing that comes up. What are my options? And now we're pleased to be able to say, well, you have multiple options. Right? Like, we didn't used to have multiple options. Now we have multiple options, which is great. And as a step forward, although it can sometimes be kind of overwhelming to now consider, you know, multiple different things, and then which one would be right for me, if any. I think we start from the standpoint, we have to remember that dietary management with avoidance is a perfectly reasonable option for lots of patients, and many people can manage that and really don't feel like they need, you know, an interventional type of treatment, that staying away from your allergen can be done and can be done effectively. And many people are able to manage that in a way that feels comfortable to them, and then they're not really interested in one of the other treatments that I'm about to talk about. I should also point out that some of these treatments depend on ongoing allergen avoidance when you use the treatment. So avoidance kind of underpins everything that we do. We can talk more about when you might think about when a treatment would be indicated, but keeping in mind that that's the baseline where we're working from, and that for many people, that seems to work just fine for them. Now, in terms of an interventional approach, where you might go beyond avoidance, probably the most commonly available option now is oral immunotherapy, or O-I-T, which I think about, and I explained to patients as a way to gradually introduce the patient orally to small and escalating amounts of the thing that they're allergic to. And so I sometimes refer to it as micro dosing. It's not about eating whatever you want. It's about very small, tightly controlled exposures that change the immune response to that allergen and result in a clinical change that we call desensitization. This is a similar concept to what we've done with allergy shots for environmental allergy patients for 100 years. If you're allergic to cat or dust or pollen, we give some of those allergens back to the patient in small doses, and the body learns to adjust. Similar idea with food allergy taken by the oral route. There is one FDA approved product that can be used for oral immunotherapy. It's currently approved only for peanut allergy and only for patients aged four to 17. Then I would also identify a second way of practicing OIT, which is fairly conventional. It's using readily available commercial food products that you might find, you know, on Amazon or at the grocery store that are not approved by the FDA for this purpose, but have been used in various protocols in both academic studies and also in routine clinical practice, and include peanut, but also include other foods as well. And there are a number of clinics around the country that might offer patients OIT in this fashion. We don't know much about those practices, even how many there are and how many patients are treated this way. There's considerable variation between clinics about how this happens, because different clinics use different food products and different protocols. And so a lot of differences in the way oit is practiced still. And most patients around the country probably still don't have access to a clinic like this, because the number of physicians that are offering OIT this way is estimated to still be pretty small. And then I would put even, like, a third category of OIT that would be more of an unconventional or unusual approach to practicing OIT, where the approach might be to start with different allergens than the one you're allergic to and kind of work your way towards the food you're allergic to, which has been referred to as using biosimilar proteins, which is a whole different thing. And I would put as a third way of approaching OIT. We don't know that much about that. That hasn't been published much. And there's one particular clinic that advocates for this approach. Now, there is in some small, probably a small number of clinics, many of which actually offer OIT. Some are starting to dabble a little bit in sublingual immunotherapy or SLIT. And sublingual immunotherapy is kind of like OIT, same concept. We're exposing patients to what they're allergic to. But instead of hundreds of milligrams or even grams worth of the dose that you're taking every day, sublingual immunotherapy, or SLIT, tends to be a few milligrams. So it's a much, much smaller dose. It's delivered in a liquid and it goes under the tongue. It's a similar concept, exposure, immunotherapy, gradually building the dose, but the doses stay much smaller, and they're delivered under the tongue rather than prepared in a food and swallowed. Now, the most recent treatment option that's available as of mid February, is an anti IgE biologic called Omalizumab. The trade name is Zolair, which is now FDA approved for the treatment of one or more food allergies in patients one and above, including adults. This is a treatment that is now more and more available. Many allergists have a comfort level and a history experience using Zolair because it's been approved for allergic asthma for many years, almost 20 years, including his kids as young as six. This is an approach that creates a similar change that we see with immunotherapy. That change we call desensitization. But instead of exposing oneself to one's allergens to achieve that desensitization, we give this medicine in the form of a shot that's given either once or twice a month. For some patients, the concept of taking a pharmaceutical product or an injection may not be so palatable. But the thing about Zolair that's interesting is, number one, you get the desensitization without exposure to allergen. So the risk of reacting to the treatment itself is minimal, almost zero. It's given once or twice a month instead of every day. It's effective against multiple allergens. So we really haven't had a good way to approach the 30% to 40% of patients who are allergic to multiple foods. It's approved down to age one and up to adulthood. So we haven't had anything that was FDA approved in those age groups before this. That's a big milestone, to now have a treatment option that could potentially be used in so many more patients and at a scale where allergists are comfortable using that product. So we'll talk more about this. But that happened just in mid February. So this is relatively still quite new. And I would say while it addresses a lot of important issues and kind of fills an important gap, there's still a lot of questions about who's an appropriate treatment candidate? How do we really use this medicine? I'm sure we'll talk more about that in the future. Then. I would also just point out, too, that although these are not necessarily readily available everyday treatments now, which is what you pointed to in your question, there still is a lot of research going on. There is a whole pipeline of products that are still considered investigational in clinical trials, forms of immunotherapy that are given now by injection or via a patch on the skin, and then other molecules, including medicines that might be taken by mouth, that could potentially produce desensitization. So you don't have to take a shot. There's a whole pipeline of things that are still being worked on that are not available to patients in practice right now. If you happen to be near a research center, you might have an opportunity to participate in a clinical trial. We hope that this landscape will continue to evolve with more and more options that are more and more safe and effective and patient friendly. And maybe we'll talk about some of those other things on a future episode when we have more data.

[13:52] Caroline: Definitely, we will. And thank you so much for giving that clear explanation. It still just blows my mind. Children are in their twenties in college, and I remember writing the letters to Genentech and Novartis way back in the day about Zolair. So it was really, or actually it was TNX-901. So it was really kind of interesting to see what is now becoming available. So this is really exciting. But you had mentioned earlier about, you know, when should you look at treatment? So can we slide that question in here? When should someone look at treatment? We're going to talk about next? You know, how does a family decide what option is best? And as we go into that, if you don't mind covering, you know, time commitment and the lifestyle and the impact on the family's budget. But when do they even, you know, start looking like, even, you know, for someone like sage, me as an example. Right. Like, should we start looking at things right now, someone who has a five year old? When do you start looking at stuff?

[14:52] Dr. Brian Vickery: Well, there's no harm in looking. You know, I would say one thing that the food allergy community really tends to excel at is engagement and, you know, awareness and education. And I really appreciate what you're doing here, what your organization does to get people the information they need. And so there's no harm in doing your homework, reading up on these things. Speaking to your allergist about could this be a good option for our family? What are the kind of the risk, benefits and trade offs? Because ultimately, a lot of this comes down to a discussion between a provider and a family. At the individual level, these cases are full of nuance. Everybody's perspectives are going to be valid and different. Call that shared decision making, really, where there's a partnership between the provider and the family. And so I think it's important to kind of equip yourself with as much information as you can going into that conversation. At some level, that's a what it comes down to. How do you know if you're in the ballpark, if you should be considering an interventional treatment option? I would say I'm interested in this question. And really, what does it look like to live well with food allergy? There are lots of people who do it without a treatment. So what does it look like to have your needs met to fulfill your goals? I mean, you know, it's a chronic condition. It's potentially life threatening. It's burdensome. It affects quality of life. We know all that, but those impacts are felt differently by different people, and I don't think we quite understand that difference. There are some people who manage to adjust reasonably well to those impacts and carry on and feel like when you offer them a treatment discussion. They're like, no, we're good. Can you cure my child's allergy safely? Can you make it go completely away? Is there something like that would just put all this behind us? Well, I should point out, unless it's in case it's not clear, like, none of the things I'm talking about today are cures. It's not something we can offer yet. We're still working on that. But we can't make the allergy go completely away. What we're doing is these temporizing measures, the goal of which is largely to protect people from the consequences of accidental exposures. Right. So while you're still managing through avoidance, like I talked about, and despite all of your precautions and vigilance, accidents happen. And we know this. Accidents happen at school, accidents happen in the kitchen, at a restaurant, despite everybody taking your food allergy seriously, and sometimes when they don't. And these treatments are geared around how do we protect people from those accidental exposures that are great sources of stress, are sources of medical suffering, symptoms, and so on, and really create what I would almost refer to as sort of a peace of mind around helping people navigate their everyday environments. To go to school, to go to camp, to travel for work, to navigate those spaces where allergens may be present and provide some protection from the inevitable accident that'll happen. And if that kind of value proposition resonates with you and your family, like, yeah, I would love that. That's what I feel like I really need. Yeah, I'd love a cure. But short of a cure, something like that would be a really important step forward for us. Then you should start talking about treatments again, there are people who that kind of value proposition may not be as important. And again, when you talk about, like, the costs associated with therapy, the number of visits, the burden, the other things that we'll talk about in a few minutes, for some people, it's going to net out like, yeah, we're okay, kind of where we are. We can manage through those spaces. Okay. For others, that's going to be a real priority. To say, like, I would love the concept of a decent civilization where I know my child's protected from small exposures, still not eating whatever they want to, still not cured, but largely protected. When I turn my child over to the camp counselor or to the school teacher or put them in the hands of the chef, I know in the back of my mind that they're protected and that creates value for us. That's where you want to have a conversation about treatments.

[19:23] Caroline: Great. Thank you. I think that was so key and so important. So now let's go a little deeper into time commitment, lifestyle changes, and then the impact on families. Budgethouse. I mean, obviously, each of these treatments are very different, but I do think there is a little bit of a common thread that there has to be family time commitment. We do have to reach into our pockets if we're missing work, you know, or paying for the actual treatment, insurance coverage and all that. So if you don't mind talking about that now.

[19:53] Dr. Brian Vickery: Yeah. So if, again, if that value proposition of desensitization starts to resonate with, with a family, then we kind of engage in sort of a shared decision making kind of exercise that we talked about. To me, that that's like, let's start to analyze what your goals are. What would you want to imagine for yourself or for your child in terms of their diet? Are they interested in being exposed to the food or not exposed to the food? If exposed, do you think that they would be willing to swallow it or not swallow it? What is the specific food involved? Or foods? What's the number of foods? Are they important dietary staple foods that are very hard to avoid? Foods like maybe milk and egg and wheat? What is the age of the child? And all of these things really help to understand what might be options, what might really be workable or feasible for that particular family. And I think of these things as having kind of almost like different use cases. Right? So you could imagine many different use cases. But like, a common example would be like, when I see patients, there's a, you know, 17 year old rising senior in high school, and the family's concern is, how are we going to protect this young person when they become independent and leave the house and go to college and deal with all the stresses of college and the disruptions to the schedule. And that, let's say that adolescent is allergic to tree nuts, multiple tree nuts, foods that they've been avoiding, that they have no interest in ever really eating on a regular basis but just want to be protected from. In fact, they find the experience of consuming them pretty noxious and they're very aversive to them. So that's a use case where you start to think, like, I don't know about oit as an option there, at least in my mind. Right. It's going to be hard to consume every day. It's not going to be a particularly palatable experience sending a child to their dorm room as a freshman in college with an oit kit and having them measuring and taking their own doses every day in college may not be the best idea. From a safety perspective, are there kids that can do that? Yeah, there are. But you can see that's a kind of use case, right? And that's a use case where you might think about one of these treatments like Omalizumab, which is given more infrequently, maybe once or twice a month, doesn't involve oral exposure, doesn't involve the risks of allergic reactions. Does it require daily adherence and treats multiple things? That's a use case where that matches up. On the other hand, you can imagine the opposite scenario where you have a 18 month old or a two year old who's got an allergy to a staple food, egg or wheat or one that's particularly hard to avoid. Sesame. We're hearing a lot about sesame these days, and the family's goal is really to try to reincorporate that food into the diet when the child is on the young side and they have the time to be with that child and attend the appointments, and their goal is to try to reincorporate. And that might be, that might lean us more towards an oit kind of situation. Right. So I think about those kinds of variables in a broad sense. What are the number of foods, the specific foods involved, the age of the patient, and kind of the family goals and kind of thinking about which of these interventions might be right. And then we also have to run that through what the family's capabilities are. Right. And you hinted at that, and I think of those in kind of three main ways. One is risk tolerance. What does the family feel comfortable doing? Some of these kinds of treatments involve giving allergens yourself at home. So you have to almost have to be a little bit of a nurse to prepare the dose, to give the dose, to assess the child afterward, make sure that they are not reacting to it. So you're kind of making some clinical decisions at home about is the child well enough to take a dose today? Was the dose tolerated? Do I need to do anything afterwards? Do I need to make an adjustment to the schedule? Do I need to call the physician's office? Am I comfortable giving epinephrine for a dose related reaction? All these things versus, like, that seems like a lot for me. So really, the family's level of risk tolerance for giving the treatment, you alluded to just the family's schedule and the family's resources. Some of these treatments require multiple visits to the office, and that is time away from work and school. It's time and travel. So there are certainly indirect or opportunity costs associated with all of that time. On top of that, some of these clinics do or do not file for insurance reimbursement. So some of them actually are cash only practices, and they charge patients cash for these immunotherapy services. Some will bill your insurance, but then, of course, that may result in a copay or even if you have a high deductible kind of HSA based plan like you may, for the first part of the year, really be out of pocket a lot of money until you meet your deductible. And so there may be direct costs associated with financing these treatments or medications. And these are all important things to consider when we think about, you know, is this ultimately a feasible solution that is going to work well for the family that's involved?

[25:27] Caroline: I really appreciate you helping break that down because there's so many factors, and I think, speaking as a parent, you get caught up, I don't want to say romance, but you get caught up in the excitement of the idea of a treatment or something really spectacular. But we really do need to step back and make sure we can continue it and afford it and have the time and the patience and the right personality and so forth. So I really appreciate you bringing that up. So now do you have any tips for families who really are already considering maybe one of these current food allergy treatments? And in particular, if you don't mind speaking to how parents could approach it with speaking to their children about the treatment, and then long term, because you were talking about maybe doing oit with a younger child, but then what does that look like in high school? What does that look like in college? What does that look like as an adult? So we're making decisions right now for our children's health, but once they become an adult, what happens then?

[26:32] Dr. Brian Vickery: Yeah, these are key conversations to have. And I'll say I don't have a, you know, sort of a magic bullet for them because it's nuanced and contextual. It depends on your particular child's developmental stage and their understanding of what the treatment is. And obviously that that's going to vary considerably between families. I'll say when we do research, our ethics committees require us to obtain assent. So we obtain consent from the families, from the parents, from the caregivers, when we start the study, because this is research involving minor participants, they're consenting on the child's behalf as their caregiver when the child is young. Our ethics committee requires us to obtain assent from the child him or herself when they turn seven. So just to kind of give you a sense of, like, that's around the developmental age or stage where our ethics committees agreed that the child is capable of understanding in general terms what's happening to their body, and they're able to kind of make a decision that that's something that they do or don't want to continue to pursue. So you can see it really depends on where you are on that continuum of age and your child's developmental capability to understand that within that. I think that one of the conversations has to be, look, this is not a cure. We're not doing this so that we can expect that your allergy will go away. That sets the appropriate expectations. What naturally follows then is, if it's not a cure, then how long do we need to continue it? Do I really need to do this for the rest of my life or for, for many years? And what I tell people is there's no evidence that any of these treatments would really bring the condition to an end, which means you have to approach it when you're considering it from the beginning. You have to approach it from the standpoint of, if this works for me, I can derive the benefit of the treatment for as long as I'm on the treatment. Just like with any other medication. If you stop the medication, the benefit will largely wear off over time. And that's true for almost any medication we would use for a chronic condition. Yeah, if you have an ear infection, you can take antibiotics for ten days and then stop. But if you have high blood pressure or diabetes or asthma or some other chronic condition, ongoing treatment is going to be necessary to manage the condition and food allergies like that. Now, what I also tell people is it may not look like this forever, and your willingness to continue treatment may evolve, too. So there may be people who want to use one of these treatments for a few years and then kind of reassess where they are. I would encourage people not to think about it, like, indefinitely, 25, 50 years down the road. Let's think about in the short term, let's get through this period in our life and reassess how the treatment's working for us. I also tell people, look, there's a whole pipeline of research that's still happening, which I mentioned at the beginning. And so it may well be that for some people, they continue on one of these treatments until something comes along better, that replaces it, that offers them more value, that overcomes some of the current limitations with the treatments that we have. So it's a long term perspective, and people need to know that it's not six months or a year, and then you can stop and things are totally different. It's an ongoing thing, and you've got to enter it with that mentality. But there's too much going on to say confidently that this is going to be like the rest of your life kind of thing. It's likely that the treatment landscape will continue to evolve in a way, and we'll get more data from ongoing studies and we'll be better at managing this condition from a long term standpoint.

[30:30] Caroline: That's a great point. So this has been absolutely information packs. So before we sign off, is there any last words of wisdom you want to leave our listeners with?

[30:44] Dr. Brian Vickery: Well, I mean, I think that the field is in an interesting place. Right. We, like I said when I got into it, we didn't have a lot to offer patients. Now we have multiple options. So that's, that's a good thing, right? I saw a family the other day because we're recruiting two clinical trials at the moment for, for school age kids with, with peanut allergy. This is a mom who, she has a son with peanut allergy. And when he was young and he was home with her and she could, you know, keep an eye on him all the time, she wasn't that interested in a treatment. She's like, I, I got this. I can manage him. Hes with me all the time. I know exactly what hes eating and not eating well. Now hes in the school system and his eczema has improved. That was the other thing. When he was younger, his eczema was a big deal. Thats gotten better. So now she brings him back and hes six years old and shes like, okay, im ready to do something about this. Hes in the school system. Hes not with me most of the time. His skin has gotten better. What can I do about his peanut allergy? Well, at my place, she now has five options. Right. Shes got ongoing avoidance, which is what she's been doing. We've got oit for peanut that we can use in the clinic. We've got Zolair that's now approved, and we're using that in patients. And now we've got two clinical trials for peanut allergy using different approaches in kids her age. That's great. But it was almost like you could just see her being overwhelmed with like, wow, five options. How am I going to sort through all five options? Right? It was almost like, caught her off guard, didn't know that I'd have that many choices to make. And so that's a lot to cover in a visit that towards the end of a long day, the child was a little ready to get home, didn't lend itself to a long conversation. And so while we're making improvements by creating new treatment options for people, we recognize also that navigating this increasingly complex landscape is demanding. There is clearly unequal access to treatments around the country. There's even unequal access to information. I think there are people who seem to be really up to date on the latest and greatest. There are other people who have never heard of some of these things that we're talking about right now and don't. And don't have access to a clinic that would even offer them one. So just from. From an access to information standpoint, or even access to injectable epinephrine standpoint, there's still a lot of inequity in the system. And so the field is at an interesting place. We're moving forward in some ways, but we're not clearly meeting the needs of all of our patients in the ways that count. And if it seems a little overwhelming or not sure what to do, we can understand that if a listener feels that way, that's kind of where the field is right now. These are things are happening, and some of these things are becoming available to certain people, and they're having to make decisions about them. We have a lot more work to do to make them more widely available to the people that need them, to help people understand what's right for them to really get better about. With an individual patient, your child in my office saying, okay, according to testing that I have, my understanding of your child's condition, the type of food allergy you have, treatment a is a better option than treatment b, and here's why. We don't really have that sort of patient selection segmentation thing really figured out. That gets back to my earlier comment about, like, we have a lot of work to do to ensure that these advances actually translate into better outcomes for patients. At one level, that's just simply research activity. But we also have more to do on kind of the implementation side of things, on the community engagement, public awareness side of things, addressing health inequities. For listeners out there who are interested in this, my advice would be find a good board certified allergist that is familiar with the data, that feels comfortable managing food allergy. Write all your questions down on a legal pad or whatever on your phone, bring them to the visit, and ultimately, you got to sort through these things on sort of a one on one basis with the allergist that you're engaged with and partnering with, and it takes time. These are complex, nuanced conversations. If you read stuff online that seems sensational in a positive way, like, oh my gosh, I'm hearing about these cures that are available, or it maybe seems the other direction, like it's so pessimistic, like there's no hope. You read an account of somebody who's had a terrible experience and had terrible reactions. All that stuff has to be sort of filtered through a conversation with your allergist because there's a lot of stuff online and those things are not really data. That's not a substitute for a relationship with your allergist. The field has a long way to go, but a good allergist can help you navigate what we know, what we don't know, and what might be right for your family.

[35:51] Caroline: Thank you so much for your time and for sharing your wisdom and how to break down this very overwhelming, complicated, and exciting topic. There's a lot of great information here, so thank you again, doctor Vickery, and we do look forward to having you on the podcast in the future.

[36:10] Dr. Brian Vickery: Well, Caroline, thanks for the opportunity. Since we last spoke, you know, a bunch has happened, and again, we've covered a lot of this today. The field is continuing to evolve, and that's a very exciting thing. But, but obviously, I hope I've left you with the sense that. But we still have a lot to do. So I look forward to our next conversation and hopefully we'll be a little bit farther down the road then.

[36:33] Caroline: Oh, absolutely. Thank you again. Before we say goodbye today, I just want to take one more moment to say thank you to Genentech for their kind sponsorship of Facts Roundtable podcast. Also, I want to note that today's guest was not paid by or sponsored by Genentech to participate in this specific podcast. Thank you for listening to Facts Roundtable podcast. Stay tuned for future episodes coming soon. Please subscribe, leave a review, and listen to our podcast on Pandora. Apple Podcasts, Spotify, Google podcasts, iHeartRadio and Stitcher. Have a great day and always be kind to one another.